Physical & Occupational Therapy in Pediatrics, 32(3):272–287, 2012

C 2012 by Informa Healthcare USA, Inc.
Available online at http://informahealthcare.com/potp
DOI: 10.3109/01942638.2012.662584

The Assessment of Preschool Children’s

Participation: Internal Consistency
and Construct Validity
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Mary Law1 , Gillian King2 , Theresa Petrenchik1 , Marilyn Kertoy3 , &

Dana Anaby4
1
CanChild Centre for Childhood Disability Research and School of Rehabilitation
Science, McMaster University, Hamilton, Ontario, Canada, 2 Bloorview Research
Institute, Toronto, Ontario, Canada, 3 School of Communication Sciences and Disorders,
University of Western Ontario, London, Ontario, Canada, 4 School of Physical and
Occupational Therapy, McGill University, Montreal, Quebec, Canada
For personal use only.

ABSTRACT. Participation in activities provides the means for young children to learn,
play, develop skills, and develop a sense of personal identity. The Assessment of
Preschool Children’s Participation (APCP) is a newly developed measure to capture
the participation of children aged 2 to 5 years and 11 months in the areas of play, skill
development, active physical recreation, and social activities. Data from a clinical trial
involving 120 children with cerebral palsy indicated that the APCP has moderate to very
good internal consistency. The measure distinguishes between children below or above
4 years of age across levels of the Gross Motor Classification System, and between in-
come levels below or above the median regional income range. The APCP, with a focus
on preschool children, has potential use for assessment and identification of activity ar-
eas in which the child is participating and areas in which participation may be restricted.

KEYWORDS. Cerebral palsy, leisure and recreation, play, playfulness, psychometric

testing

Participation is defined by the World Health Organization (WHO) as “involvement

in a life situation” (World Health Organization, 2001, p. 10). In addition, Coster and
Khetani (2008, p. 643) suggested that life situations are “sets of organized sequences
of activities directed toward a personally or socially meaningful goal.” Participation
in activities is the context in which young children learn, form friendships, develop
skills and competencies, express creativity, and develop a sense of personal identity
(Coatsworth, Palen, & Sharp, 2006).

Address correspondence to: Mary Law, PhD, CanChild Centre for Childhood Disability Research and School
of Rehabilitation Science, McMaster University, IAHS Bldg., 1400 Main St W., Hamilton, Ontario, Canada
L8S 1C7 (E-mail: [email protected]).
(Received 26 July 2011; accepted 21 January 2012)

272
 Assessment of Preschool Children’s 273

A majority of the recent research regarding the participation of children with

disabilities has focused on children over the age of 6 years. There has been little
research about the participation of preschool children, particularly research focus-
ing on the measurement of sets of activities. A challenge in studying participation
for children under 6 years of age is the lack of validated measures of the participa-
tion for preschool children. Such measures have potential use to identify patterns
of participation for activities for both families and service providers.
The Assessment of Preschool Children’s Participation (APCP) (King, Law, Pe-
trenchik, & Kertoy, 2006c) is a newly developed measure designed to capture the
activity participation of children aged 2 to 5 years and 11 months. The purpose of
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this paper is to provide data regarding psychometric properties of the APCP among
children with cerebral palsy. More specifically, we examined the internal consistency
and construct validity of the APCP by conducting an item analysis and testing group
differences in participation using variables that are known to be related to the con-
struct of childhood participation. To further establish validity, we examined the as-
sociation between number of health conditions in addition to cerebral palsy with
levels of participation diversity and intensity across all activity types/domains.

BACKGROUND INFORMATION
The participation of children in everyday activities is associated with the cultivation
For personal use only.

of children’s social relationships, the development of essential skills and competen-

cies (Larson & Verma, 1999; Mahoney, Larson, & Eccles, 2005), and the promo-
tion of mental, physical, and behavioral health (Sandler, Ayers, Suter, Schultz, &
Twohey-Jacobs, 2004; Wright & Masten, 2005). The preschool years are particu-
larly important for development across all areas, as development is impacted sig-
nificantly by a child’s participation in everyday social and solitary activities.
Dunst, Hamby, Trivette, & Raab (2002) examined participation in family and
community activities of preschool children from birth to 6 years who had or were
at risk for a developmental delay. Using family and community surveys with over
1,400 parents, they found that children participated in a large range of activities,
with considerable variability in individual participation patterns. The percentage of
children participating in different types of activities increased in a linear fashion as
children got older.
The participation of preschool children with disabilities has not been studied in
depth, as most research has focused on measurement of body function and structure
(e.g., reaching, range of motion, eye–hand coordination) or activity limitations (e.g.,
ability to hold a spoon independently, putting on clothes, or undo buttons). Sime-
onsson et al. (2003) wrote about the need to develop and test measures that reflect
the broad content of the new International Classification of Functioning, Disability
and Health (ICF) (WHO, 2001). They identified 14 measures commonly used in
pediatric rehabilitation, the majority of which focused on assessment of functional
and developmental areas rather than participation. Over the past decade, there has
been substantial development of health-related quality-of-life measures for chil-
dren, but less development of measures focused specifically on the participation
domain of the ICF. As well, there are several assessments of preschool play skills,
which include only one area of participation such as outdoor play.
 274 Law et al.

The Lifestyle Assessment Questionnaire (LAQ) (Jessen, Colver, Mackie, &

Jarvis, 2003) is an assessment designed to measure the impact of disability across
the participation domains of communication, mobility, self-care, domestic life, so-
cial and civic activities, and family impact. The LAQ has been used to assess impact
of disability in two studies of children 5 years of age (Forsyth, Colver, Alvanides,
Woolley, & Lowe, 2007; Welsh, Jarvis, Hammal & Colver, 2006), but is predomi-
nantly used for assessment in research with children aged over 5 years. The Func-
tional Independence Measure for Children (Wee-FIM) (Msall et al., 1994) and the
Pediatric Evaluation of Disability Inventory (PEDI) (Haley, Coster, Ludlow, Halti-
wanger, & Andrellos, 1992) are the most commonly used assessments in preschool
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intervention studies for children with rehabilitation needs. Both of these assess-
ments focus on the level of performance and include items related to mobility, self-
care, and social functioning, but do not include broader sets of activities that com-
prise preschool participation such as play and community activities.
One preschool participation assessment, which has been developed and is cur-
rently undergoing psychometric testing, is the Preschool Activity Card Sort (PACS)
(Berg & LaVesser, 2006; Stoffel & Berg, 2008). The PACS is designed to be used
to set intervention goals for children 3 to 6 years of age. The PACS covers six do-
mains using 85 activity cards. The assessment uses photographs of childhood activi-
ties across the domains of self-care, community mobility, leisure, social interaction,
domestic chores, and education. Through this assessment, parents use the activ-
For personal use only.

ity photographs to identify the activities in which their child participates and five
activities for which they wish occupational therapy services. The PACS has been
translated and tested in Spanish (Stoffel & Berg, 2008) and the English version
demonstrated that it discriminated between preschool children with and without
autism (LaVesser & Berg, 2011).
The APCP is a measure designed to document children’s participation in day-to-
day activities. The APCP is modeled after the Children’s Assessment of Participa-
tion and Enjoyment (CAPE) (King et al., 2004), which uses drawings of everyday
activities to ask parents and children about the nature and frequency of participa-
tion in recreational, active physical, social, skill-based, and self-improvement activi-
ties during non-school hours. The APCP includes 45 drawings of everyday activities
in the areas of play, skill development, active physical recreation, and social activ-
ities. Parents are asked to identify activities their child has participated in during
the past 4 months and how often they did them. In developing the APCP, we recog-
nized that the participation of preschool children is significantly influenced by their
family and the participation choices that parents make. While preschool children
can make choices about activities, these choices are based on what is available to
them in settings typically structured by adults. Thus, the participation of preschool
children is often a reflection of their family’s participation choices, child-care needs,
and opportunities available within the child’s immediate environment.
Findings from previous research on childhood participation guided the devel-
opment of hypotheses regarding construct validity of the APCP. In a sample of
preschool children without disabilities, researchers found evidence of age-related
differences in participation across groups of children at risk or with a developmen-
tal delay (Dunst et al., 2002). Studies of preschool children with cerebral palsy have
found several predictors of participation, including severity of impairment (Forsyth
 Assessment of Preschool Children’s 275

et al., 2007), the level of cognitive, motor, and communicative functioning, and
families’ district of residence (Hammal, Jarvis & Colver, 2004). Among children
aged 6 years and older with a disability, participation differences have been found
to be significantly influenced by a child’s age (Law et al., 2006), sex (King, Law,
Hurley, Petrenchik, & Schwellnus, 2010), functional ability (King et al., 2006a;
Majnemer et al., 2010; Palisano et al., 2009, level of family income (Law et al.,
2006), child preferences (King et al., 2006a), and family’s participation in social
and recreational activities (King et al., 2006a). Children with disabilities generally
participate in lower levels of recreation and leisure activities than children without
disabilities (Bult et al., 2010; Imms, Reilly, Carlin, & Dodd, 2008; King et al., 2010;
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Law et al., 2006; Majnemer et al., 2008).

The purpose of this paper is to provide an evaluation of psychometric proper-
ties of the APCP with respect to its ability to discriminate patterns of intensity and
diversity of participation as a function of children’s age, sex, level of gross motor
function, and annual family income. Data presented in this paper were collected
through a randomized controlled trial evaluating the efficacy of a child-focused ver-
sus context-focused intervention in improving performance of functional tasks and
mobility in young children with cerebral palsy (Law et al., 2011). The trial included
128 children with cerebral palsy across Levels I–V on the Gross Motor Classifica-
tion System (GMFCS) (Palisano et al., 1997). Children received child-focused (N =
71) or context-focused intervention (N = 57) over 6 months, returning to their regu-
For personal use only.

lar therapy schedule and approach between the end of intervention at 6 months and
follow-up at 9 months. The primary outcome was performance on the PEDI (Haley
et al, 1992). Outcome evaluators were masked to group assignment and completed
assessments at baseline, 6 months, and 9 months. The analyses in this paper used
the baseline data for children in the trial who were 2 to 5 years and 11 months of
age (N = 120). The analyses were designed to investigate the following hypotheses
regarding the construct validity of the APCP:

1. Children over 4 years of age will be involved in more activities than younger
children, but not more frequently.
2. Girls will participate in more social activities than boys; boys will participate in
more active physical recreation activities, and more frequently.
3. Children with higher levels of impairments in self-care and motor functioning
or higher number of health conditions will participate in fewer activities and
with less frequency than children with lower levels.
4. Children living in families with higher median annual incomes will participate
in more activities and with greater frequency than children living in lower in-
come families.

Participants
Participants were 120 children with cerebral palsy who were between 2 years and 5
years and 11 months of age and attended one of 19 children’s rehabilitation centers
in Ontario and Alberta, Canada. Ethics approval for the study was obtained from
the Office of Research Ethics at McMaster University and the University of Al-
berta, and parents provided informed consent for the study. The sample included
 276 Law et al.

TABLE 1. Characteristics of 120 Children with Cerebral Palsy

Variable Category N %

Sex Boys 71 59.2

Girls 49 40.8
GMFCS Level I 36 30
Level II 21 17.5
Level III 18 15
Level IV 21 17.5
Level V 24 20
Family income <$15,000 7 6.7
$15,000–$29,999 11 9.2
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$30,000–$44,999 14 11.7
$45,000–$59,999 15 12.5
$60,000–$74,999 13 10.8
$75,000–$89,999 18 15
≥$90,000 34 28.3
Missing 7 5.8
Family unit Two-parent family 106 88.3
Single parent family 13 10.8
Missing 1 0.8
Ethnicity background Caucasian 92 76.7
Asian 9 7.5
African-American 6 5
Latin 4 3.3
N. American Indian 3 2.5
For personal use only.

Others 6 5
Community Large metropolitan 23 19.2
Medium metropolitan 38 31.7
Small-metro 25 20.8
Non-metro urbanized area 19 15.8
Rural 15 12.5
Additional health conditions Behavioral disorder 3 2.5
Developmental delay 61 50.8
Seizure disorder 30 25
Vision impairment 42 35
Hearing impairment 9 7.5
Learning disorder 15 12.5
Others 33 27.5

120 children aged 2 to 6 years (mean = 4.1, SD = 1.1), all diagnosed with cerebral
palsy. The number of additional health conditions ranged from 0 to 6 (mean = 1.3,
SD = 1.3, median = 1). Table 1 summarizes additional demographic and clinical
information for the children in the study and their families.

Measures
The evaluation of psychometric properties of the APCP used data from several
outcome measures. The PEDI (Haley et al., 1992) was used to measure the perfor-
mance of functional tasks of self-care and mobility. Each domain, i.e., self-care and
mobility, is measured using a Functional Skills Scale (FSS) that is rated as 0 (un-
able, or limited capacity to perform the skill) or 1 (able to perform the skill), and
a Caregiver Assistance Scale (CAS) that is rated from 0 (total assistance) to 5 (in-
dependent). Thus, four scores are generated from the PEDI. The PEDI has been
 Assessment of Preschool Children’s 277

validated in many studies and has excellent reliability and validity for this study
population.
The GMFCS (Palisano et al., 1997) is a five-level system that classifies children’s
gross motor function in everyday routines within four age strata. Specific levels on
the GMFCS are based on the child’s motor abilities and use of mobility devices.

APCP Development
The APCP is a paper and pencil, parent completed questionnaire containing 45
drawings of everyday activities. Parents are asked to identify activities their child
has participated in during the past 4 months and how often they did them, as done
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in the CAPE (King et al., 2006b). The purpose of the assessment is to capture
preschool children’s activity patterns in the areas of play (e.g., playing with toys, cre-
ating a craft), skill development (e.g., drawing and coloring, taking music lessons),
active physical recreation (e.g., riding a tricycle, playing on playground equipment),
and social activities (e.g., playing a board game, going on an outing). The APCP re-
flects the conceptual framework underlying WHO’s (2001) ICF. This framework
distinguishes between impairments, activity limitations, and participation restric-
tions. The APCP focuses on a subset of the ICF domains of participation. The items
constitute a categorization of sets of activities based on a comprehensive review of
the literature and feedback from families through a pilot study, as well as items
from the CAPE (i.e., skill-based, physical, and social) and scoring scales deemed
For personal use only.

appropriate for younger children. The APCP includes 7 items not in the CAPE, 23
identical items, and 15 similar items modified to fit preschool children.
Like the CAPE, the APCP captures aspects of children’s participation in a range
of non-academic activities in a variety of everyday environments, including home,
preschool, nursery school, or kindergarten and child care arrangements such as day
care, before and after school programs, and supervised care. Unlike the CAPE, the
APCP is parent-completed (rather than child- or youth-completed) and does not
include measurements of where and with whom activities take place, or the child’s
rating of enjoyment. The items selected for use in the APCP reflect the most com-
mon types of everyday activities discussed in the literature across populations of
children and age groups. Item generation was based on review of developmental
literature and existing measures of participation, which excluded basic self-care ac-
tivities.
The initial version of the APCP included 43 items; initial pilot testing identified
additional five new items, for a total of 48 items. As previously indicated, items are
organized into four activity areas, three of which are in the CAPE—play activities,
skill development, active physical recreation, and social activities. On the assess-
ment, parents identify “yes” or “no” to indicate whether their child participates in
each activity. If the child does participate, they record how often the child partici-
pated over the past 4 months using a 7-point ordinal scale ranging from once over
the past 4 months to once daily or more. Two scores are generated for each item and
across the four activity areas. Participation diversity is a count of the total number
of a child’s reported activities over the previous 4 months. For group data, diver-
sity can also be reported as a percentage of activities overall and by activity type.
Participation intensity represents the average amount of time that a child spends
participating in activities across the total number of possible activities. Intensity
 278 Law et al.

is calculated by dividing the sum of frequency across all items by the number of
possible items in each activity area. Preliminary testing with 57 parents of children
with typical development attending four local day care centers in southern Ontario,
Canada indicated that the activity scales had levels of internal consistency between
0.60 and 0.70; these levels improved after the elimination of three items that were
endorsed less than 10% of the time, resulting in a final measure of 45 items. Ad-
ministration time was approximately 30–40 min.

Data Analyses
The internal consistency reliability of the APCP was examined through an item
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analysis of the intensity scale for each of the four activity domains, i.e., play (9
items), skill development (15 items), active physical recreation (10 items), and so-
cial (11 items) activities. Cronbach’s alpha values were reported; values greater than
0.7 were considered acceptable internal consistency (Portney & Watkins, 2000).
In order to examine whether the APCP can distinguish between subgroups, the
sample of 120 children was divided into groups by age, sex, family income, and GM-
FCS levels. Two age-related subgroups were created by dividing the sample into
groups of children based on whether they were under or over the age of 4 years,
based on developmental theory (Piaget & Inhelder, 1964), in which the preoper-
ational stage (age 2 to 6) is divided into two sub-stages, and the age of transition
to full-time academic-based schooling). Based on these criteria, 45% of the chil-
For personal use only.

dren were under 4 years of age and 55% were 4 years old and above. Children were
then assigned to subgroups based on GMFCS levels to examine whether the APCP
differentiated children based on GMFCS level. As in research conducted by Majne-
mer et al. (2008) and Palisano et al. (2009), the five GMFCS levels were collapsed
to form two groups: children classified in GMFCS levels I–III (62%) and children
classified in GMFCS levels IV–V (38%). Annual family income, which did not vary
significantly by province, was measured by classifying family income as $60,000 or
above, based on the median income in the 2006 Canadian census (Statistics Canada,
2006). Based on this classification, 43% of the families had annual incomes lower
than $60,000, while 57% reported above median incomes.
Independent t-tests were performed to test the differences among the subgroups
(i.e., age, sex, income, and GMFCS), and consequently examine construct validity
of the APCP. In order to test the magnitude of the differences, effect size values
were calculated based on the omega square (ω2 ) formula: ω2 = (t2 – 1)/(t2 + N1 +
N2 – 1)1 . These values were interpreted according to Kirk’s classification (1996),
where ω2 = 0.01 was considered as a small, ω2 = 0.059 as a medium, and ω2 = 0.138
as a large effect size. Analysis of covariance was performed to verify that the differ-
ences in the GMFCS are still observed while controlling for sex, age, and income.
Finally, to examine the association between number of additional health conditions
and levels of participation, and to test the association between the APCP and PEDI
scores, Pearson correlations were performed. The magnitude of correlation coeffi-
cients was considered moderate if >0.40 and strong if >0.60 (Domholdt, 2000). The
level of significance (two-tailed) was set to 0.01 because of the number of analyses
conducted. SPSS 19 was used to conduct all statistical analyses.

1t = t-statistic; N1 = number of participants in group 1; N2 = number of participants in group 2.

 Assessment of Preschool Children’s 279

TABLE 2. Internal Consistency of Items in Each Activity Type

Number of Children Number of Items Cronbach’s Alpha

Participation intensity
Play 118 9 0.65
Skill development 113 15 0.70
Active physical recreation 89 10 0.52
Social 116 11 0.66
Participation diversity
Play 118 9 0.76
Skill development 115 15 0.85
Active physical recreation 119 10 0.76
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Social 120 11 0.73

RESULTS

Internal Consistency
The Cronbach’s alpha coefficient for the four domains of the APCP varied from
0.73 to 0.85 for diversity scores and from 0.52 to 0.70 for intensity scores (see Table
2). Since the Cronbach’s test uses list-wise deletion for missing values, only 89 chil-
dren were included in this analysis for the Active Physical Recreation scale, as the
remainder did not take part in these activities at all, so did not have a diversity or
For personal use only.

intensity score.

Construct Validity
As shown in Table 3, significant differences in participation intensity and diversity
were found between children under 4 years of age (N = 54) and children above 4
years of age (N = 66) across all activity types with the exception of diversity and
intensity of active physical recreation activities and intensity of play activities. Chil-
dren aged 4 years and older participated in a greater variety of activities (i.e., di-
versity) and more frequently (i.e., intensity) than younger children (under 4 years
of age). Effect size values were medium (ω2 = 0.07) for participation diversity in
skill development, social and total activities, and small for diversity of play activ-
ities (ω2 = 0.02). We further explored whether specific items changed by age and
found that one item, team sports, was reported in the older group and children with
the GMFCS levels < III.
Significant differences in participation diversity and intensity across all activity
types were found between children classified in the GMFCS levels I–III compared
with children in levels IV–V. Children in levels I–III or less participated in a greater
range of activities and more frequently than children in levels IV–V. Effect size
values, calculated by ω2 , were large and ranged from 0.21 to 0.23 with the exception
of overall diversity and intensity of social activities, in which effect size values were
medium to large (ω2 = 0.08–0.16). Analyses of covariance accounting for child age,
sex, and family income indicated similar differences (8.3 < F < 53.5, p < .005) with
similar effect size (0.07 to 0.33) in participation patterns between GMFCS groups.
Significant differences in participation diversity were found between income
levels across all activity types. Income-related differences were significant for the
intensity of play and skill development activities, but not for intensity of social
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280
TABLE 3. Descriptive Data and t-tests, and Effect Size (ω2 ) for Assessment of Preschool Children’s Participation
Age Group Income Levels Sex

GMFCS
Levels
<4 yr ≥4 yr ≤III ≥IV <$60,000 ≥$60,000 Boys Girls
M (SD) M (SD) t ω2 M (SD) M (SD) t ω2 M (SD) M (SD) t ω2 M (SD) M (SD) t ω2

Play
Diversity 60.7 (23.8) 70.1 (26.7) −2.0∗ 0.0 76.5 (18.3) 48.1 (26.9) 6.3∗∗∗ 0.2 58.1 (28.4) 71.1 (23.1) −2. 7∗∗ 0.1 61.5 (23.8) 72.0 (27.4) −2.3∗ 0.0
Intensity1 3.7 (1. 3) 3.9 (1.5) −1.1 N/A 4.4 (1.0) 2.8 (1.6) 5.7∗∗∗ 0.2 3.3 (1.6) 4.1 (1.2) −3∗∗ 0.1 3.5 (1.4) 4.2 (1.4) −2.6∗ 0.1
Skill
Diversity 44.5 (20.8) 57.4 (22.4) −3.3∗∗ 0.1 61.1 (16.5) 35.7 (22.4) 6.6∗∗∗ 0.3 44.2 (25.7) 51.5 (23.9) −2.6∗ 0.1 48.5 (21.5) 56.0 (23.5) −1.8 N/A
Intensity 2.5 (1.19) 3.1 (1.3) −2.9∗∗ 0.1 3.4 (0.9) 1.9 (1.3) 6.6∗∗∗ 0.3 2.5 (1.5) 3.1 (1.1) −2.2∗ 0.0 2.7 (1.3) 3.0 (1.3) −1.5 N/A
Physical
Diversity 46.1 (24.6) 53.8 (25.5) −1.7 N/A 60.8 (19.5) 32.8 (24.3) 6.9∗∗∗ 0.3 43.8 (26.8) 54.8 (23.9) −2. 3∗ 0.0 46.0 (24.0) 56.0 (26.0) −2.1∗ 0.0
Intensity 2. 5 (1.2) 2.9 (1.2) −1.7 N/A 3.1 (1.1) 2.0 (1.1) 4. 9∗∗∗ 0.2 2.6 (1.3) 2.8 (1.2) −0.8 N/A 2.6 (1.3) 2.9 (1.3) −1.5 N/A
Social
Diversity 49.2 (22.4) 62.3 (23.8) −3.1∗∗ 0.1 62.2 (22.8) 46.7 (23.1) 3.6∗∗ 0.1 49.6 (21.9) 61.5 (24.7) −2.7∗∗ 0.1 53.0 (22.0) 61.0 (25.8) −1.9 N/A
Intensity 1.98 (0.8) 2.6 (1.1) −3.3∗∗ 0.1 2.6 (1.02) 1.9 (0.95) 3.4∗∗ 0.1 2.1 (1.03) 2.4 (1.05) −1.5 N/A 2.1 (0.9) 2.6 (1.1) −2.3∗ 0.0
Total
Diversity 49.2 (20.4) 60.3 (21.8) −2.9∗∗ 0.1 64.4 (16.3) 40.3 (21.7) 6.5∗∗∗ 0.3 48.2 (23.2) 60.0 (20.1) −2. 9∗∗ 0.1 51.7 (20.0) 60.5 (23.0) −2.2∗ 0.0
Intensity 2.6 (0.98) 3.1 (1.1) −2.4∗ 0.0 3.3 (0.85) 2.1 (1.1) 6.4∗∗∗ 0.3 2.6 (1.2) 3.1 (0.98) −2.3∗ 0.0 2.7 (1.0) 3.2 (1.2) −2.3∗ 0.0
∗
p < .05; ∗∗ p < .01; ∗∗∗ p < .001.
N/A = when t was not significant, ω2 was not calculated/applicable.
Diversity scores are calculated as percentages.
1
Maximum intensity score is 7.
 Assessment of Preschool Children’s 281

TABLE 4. Pearson Correlations Between the Number of Additional Health Conditions and
Assessment of Preschool Children’s Participation Scores

Skill Active Physical

Play Development Recreation Social Total

N r N r N r N r N r

Diversity 120 −0.27∗ 120 −0.33∗∗ 120 −0.38∗∗ 120 −0.35∗∗ 120 −0.37∗∗
Intensity 119 −0.29∗ 120 −0.40∗∗ 115 −0.32∗ 119 −0.37∗∗ 119 −0.41∗∗
∗
p < .01; ∗∗ p < .001.
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and active physical recreation activities. Children of families with higher median
incomes participated in more activities and more frequently than children of
families with lower median income. Effect size values were small to medium for
diversity and intensity (0.03 to 0.07). When analyses of variance were performed
to account for child age and sex, similar differences (.002 < p < .022) with similar
effect sizes (0.04 to 0.09) were observed.
Differences between boys and girls were found in participation diversity and in-
tensity in play and total activities in which girls participated in a broader range of
activities and more frequently than boys (effect size ranged from 0.03 to 0.05). In
addition, girls participated more intensely in social and more diversely in active
For personal use only.

physical recreation activities (effect size values were low, both 0.03).
Significant negative correlations were found between number of additional
health conditions and level of participation diversity and intensity across all ac-
tivity types (see Table 4). In other words, higher the number of additional health
conditions, lower the diversity and intensity of a child’s participation in everyday
activities.
Finally, positive moderate to strong correlations were found between partici-
pation diversity and intensity and levels of performance of self-care and mobility
(PEDI scores) across all activity types (0.51 < r < 0.78, p < .001). Higher the level
of functional skills and independence in performing self-care and mobility tasks,
higher the levels of participation (see Table 5).

DISCUSSION
This paper describes initial validation data for use of the APCP with children with
cerebral palsy. Results indicate that the internal consistency of the APCP is good
to excellent for diversity scores and moderate for the intensity scores. The rela-
tively lower value of Chronbach’s alpha for the active physical recreation intensity
scale (0.52) may reflect variability in frequency of participation across children with
cerebral palsy in the study sample. Notably, internal consistency values for the in-
tensity scores were not expected to be high, as many factors are expected to influ-
ence frequency of participation (King et al., 2006a). Further examination of internal
consistency in larger samples of children with cerebral palsy and across a range of
diagnoses and developmental stages will indicate whether the current structure of
the four scales for the assessment is appropriate.
 Phys Occup Ther Pediatr Downloaded from informahealthcare.com by Eastern Kentucky University on 03/20/13
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282
TABLE 5. Pearson Correlations Between Pediatric Evaluation of Disability Inventory (PEDI) and Assessment of Preschool Children’s Participation
Scores

Active Physical
Play Skill Development Recreation Social Total

Diversity Intensity Diversity Intensity Diversity Intensity Diversity Intensity Diversity Intensity

PEDI self-care
Functional skills 0.73∗ 0.70∗ 0.73∗ 0.73∗ 0.71∗ 0.60∗ 0.64∗ 0.61∗ 0.78∗ 0.77∗
Caregiver assistance 0.69∗ 0.68∗ 0.73∗ 0.72∗ 0.71∗ 0.59∗ 0.61∗ 0.55∗ 0.76∗ 0.75∗
PEDI mobility
Functional skills 0.65∗ 0.65∗ 0.71∗ 0.71∗ 0.72∗ 0.62∗ 0.57∗ 0.54∗ 0.74∗ 0.73∗
Caregiver assistance 0.67∗ 0.65∗ 0.71∗ 0.73∗ 0.68∗ 0.55∗ 0.54∗ 0.51∗ 0.73∗ 0.71∗
∗
p < .001.
 Assessment of Preschool Children’s 283

The APCP characterized differences in participation for children with cerebral

palsy who were under and over 4 years of age. As hypothesized, when compared
with the younger group, children over the age of 4 participated in a broader range of
activities and did so with greater intensity. This finding is consistent with develop-
mental theory, which indicates a broadening of interests and activities as preschool
children engage in activities outside their home environment more often and begin
to be involved in more social play (Piaget & Inhelder, 1964). Dunst and colleagues
(2002) also found that the percentage of children at risk for or with a developmen-
tal delay who participated in family and community activities increased significantly
from birth to 6 years. Similarly, our findings indicate a higher intensity of partici-
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pation in skill and social development activities in children with cerebral palsy as
their age increases.
Participation profiles of children with disabilities over the age of 6 have found
significant differences in both diversity and intensity of participation between boys
and girls (Engler-Yeger, 2009; King et al., 2010). Our findings that girls participated
more frequently in social activities than boys are similar to the results of studies of
children more than 6 years of age (Law et al., 2006). Although the effect size was
small, we also found that preschool age girls had more diverse and intense play par-
ticipation, as well as more diverse active physical participation than boys, contrary
to our hypothesis. In our sample, there were more girls with better gross motor
functioning (GMFCS I–III) than boys; this might explain the differences in par-
For personal use only.

ticipation levels in these activities. However, no significant correlation was found

between sex and GMFCS levels (χ 2 = 2.8, p = .09). It is plausible that at this early
development stage (age 2 to 6), the social implications of the sex of the children
do not come into play as much as in later age groups. Also, the greater levels of
participation observed in girls may reflect the fact that girls typically develop faster
than boys during the preschool years.
Diversity scores of children with cerebral palsy were significantly influenced by
levels of family income for all areas; intensity scores were influenced in the activ-
ity areas of play and skill activities and overall participation. These findings are
similar to other studies completed with children over 6 years of age (Law et al.,
2006), which have found income related restrictions in participation in children’s
everyday activities. This finding highlights the need to make universally accessible
early intervention programs and community organizations (e.g., YMCA) available
to low-income families.
The construct validity of the APCP is supported by the findings of significant
differences, with medium to large effect sizes, across all activity types between chil-
dren classified in levels I–III and children in levels IV–V on the GMFCS, even af-
ter adjustment for the effects of age, sex, and income. Likewise, parents of children
with a higher number of health and development conditions reported both lower
diversity and intensity of participation across all activity types. Cerebral palsy is a
condition characterized by primary motor impairment, and is also associated with
many other health and development conditions such as cognitive impairment, com-
munication disorders, epilepsy, and visual and perceptual dysfunction (Dormans &
Pellegrino, 1998). While the finding that GMFCS level and number of health and
development conditions are significantly related to participation is not surprising,
it does highlight the need to assess levels of participation at an early age. Provision
 284 Law et al.

of information about participation opportunities and strategies for parents, as well

as intervention to modify environments to support participation, can be started at
an early age if assessment indicates participation restrictions.
For families and rehabilitation practitioners, the APCP can be used to capture a
child’s overall level of participation, including the diversity and intensity of activ-
ity engagement. Service providers and researchers can use the APCP to assess and
monitor children’s participation in specific types of activities or patterns of partic-
ipation, both of which answer basic questions about the nature of preschool chil-
dren’s participation.
These analyses have several limitations. First, the results are from a relatively
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small sample of children diagnosed with cerebral palsy. Additional studies, includ-
ing larger samples of children with and without disabilities, will provide additional
information about the psychometric properties of this assessment. Likewise, exam-
ination of test-retest reliability and confirmation of the factor structure is required.

CONCLUSION
The APCP is a newly developed measure designed to capture the participation of
children aged 2 to 5 years and 11 months in the areas of play, skill development,
active physical recreation, and social activities. In this study involving 120 children
with cerebral palsy, evidence of internal consistency and the ability to distinguish
For personal use only.

groups of children with cerebral palsy based on a child’s age, sex, GMFCS levels,
and level of family income. The APCP, with focus on preschool children, has po-
tential use for assessment and identification of activity areas in which the child is
participating and areas in which participation may be restricted.

ACKNOWLEDGMENTS
Our sincere thanks to the families, children, and therapists who participated in this
study. Trial registration number: R01HD044444. This study was funded by the Na-
tional Institutes of Health, USA. We appreciate the research coordination work
provided by Mary Forhan in the development of this measure. Mary Law holds the
John and Margaret Lillie Chair in Childhood Disability Research.
Declaration of interest: The authors report no conflicts of interest.

ABOUT THE AUTHOR

Dr Mary Law, PhD, is affiliated with CanChild Centre for Childhood Disability
Research and School of Rehabilitation Science, McMaster University, Hamilton,
Ontario, Canada. Dr Gillian King, PhD, is affiliated with Bloorview Research Insti-
tute, Toronto, Ontario, Canada. Dr Theresa Petrenchik, PhD, is affiliated with Can-
Child Centre for Childhood Disability Research and School of Rehabilitation Sci-
ence, McMaster University, Hamilton, Ontario, Canada. Dr Marilyn Kertoy, PhD,
is affiliated with School of Communication Sciences and Disorders, University of
Western Ontario, London, Ontario, Canada. Dr Dana Anaby, PhD, is affiliated with
School of Physical and Occupational Therapy, McGill University, Montreal, Que-
bec, Canada.
 Assessment of Preschool Children’s 285

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